| |
34 Main Street Ext Ste 104 Plymouth MA 02360-3375 | |
(801) 655-5450 | |
Not Available |
Full Name | |
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Speciality | Counselor |
Location | 34 Main Street Ext Ste 104, Plymouth, Massachusetts |
Authorized Official Name and Position | Whitney Hebbert (OWNER) |
Authorized Official Contact | 8016555450 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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1469 N 1200 W Orem UT 84057-2449 Ph: () - | 34 Main Street Ext Ste 104 Plymouth MA 02360-3375 Ph: (801) 655-5450 |
NPI Number | 1689445488 |
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Provider Enumeration Date | 01/10/2024 |
Last Update Date | 08/06/2024 |
Certification Date | 08/06/2024 |
Medicare PECOS PAC ID | 8426595406 |
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Medicare Enrollment ID | O20240808001174 |
Identifier | Type | State | Issuer |
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1689445488 | NPI | - | NPPES |
Taxonomy | Type | License (State) | Status |
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101YM0800X | Counselor - Mental Health | (* (Not Available)) | Primary |
Provider Name | Dylan Wallace |
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Provider Type | Practitioner - Clinical Social Worker |
Provider Identifiers | NPI Number: 1982269155 PECOS PAC ID: 3173060076 Enrollment ID: I20240808001881 |
Provider Name | Josie Osborn |
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Provider Type | Practitioner - Mental Health Counselor |
Provider Identifiers | NPI Number: 1134579840 PECOS PAC ID: 0446790042 Enrollment ID: I20240910003075 |
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